Provider Demographics
NPI:1235711532
Name:DUREN, HOLLY RENEE
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:RENEE
Last Name:DUREN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4140 RICHARD AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:HERMANTOWN
Mailing Address - State:MN
Mailing Address - Zip Code:55811-3309
Mailing Address - Country:US
Mailing Address - Phone:218-514-5230
Mailing Address - Fax:
Practice Address - Street 1:4140 RICHARD AVE STE 200
Practice Address - Street 2:
Practice Address - City:HERMANTOWN
Practice Address - State:MN
Practice Address - Zip Code:55811-3309
Practice Address - Country:US
Practice Address - Phone:218-514-5230
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-26
Last Update Date:2022-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN103K00000X
106S00000X, 103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1588993091Medicaid